1528033909 NPI number — KENSINGTON VALLEY ORTHOTIC & SPORTS SERVICES

Table of content: (NPI 1528033909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528033909 NPI number — KENSINGTON VALLEY ORTHOTIC & SPORTS SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENSINGTON VALLEY ORTHOTIC & SPORTS SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528033909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 215
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMBURG
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48139-0215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-231-6905
Provider Business Mailing Address Fax Number:
801-231-6906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10020 PROFESSIONAL CANTER DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMBURG
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48139-0215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-231-6905
Provider Business Practice Location Address Fax Number:
810-231-6906
Provider Enumeration Date:
02/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MINERT
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
QUENTIN
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
810-231-6905

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4489299 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 510D703120 . This is a "BLUE CROSS BLUE SHIELD MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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